Plantar Fibromatosis Treatment & Management

Updated: Jul 10, 2018
  • Author: Amanda T Moon, MD; Chief Editor: Dirk M Elston, MD  more...
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Treatment

Medical Care

No medical care is effective in plantar fibromatosis, and reported success probably is due to the possible spontaneous involution of superficial plantar fibromatosis. Early treatments have included anti-inflammatory medication, orthotics, and physical therapy. Other modalities have included methotrexate and radiation after surgery.

For Ledderhose disease, the conservative treatment options are numerous, including offloading pads, radiation, extracorporeal shockwave, antiestrogens, verapamil, collagenase injection, colchicine, and 5-fluorouracil injection. Offloading pads as well as extracorporeal shockwave have been shown only to provide symptomatic relief, with the latter providing some softening of lesions. Ionizing radiation and intralesional injections of corticosteroids have been shown to reduce the size of lesions. It is important to note that the remaining treatments have no in vivo data demonstrating efficacy (antiestrogens), have only been shown to be efficacious in similar disorders like Dupuytren contracture or Peyronie disease (verapamil, collagenase), or require additional study to demonstrate efficacy (colchicine). In summary, conservative treatment certainly requires more study to determine the most efficacious modality, but collagenase, corticosteroids, and 5-fluorouracil injections are being used with variable success. However, pain associated with the injections can be a limiting factor in their use. [7]

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Surgical Care

For Ledderhose disease, fasciectomy and excision of the fibrous tissue can represent either an initial option for patients with symptomatic lesions or a choice decided upon after conservative treatment fails. Fasciectomy has been shown to reduce the rate of recurrences and can be of the local, wide, or radical complete plantar variety. [7, 14] The choice of type of fasciectomy must be weighed with the risk of complications, especially recurrence, which can be 57-100%, less than 50%, and 0-50%, for local, wide, and complete plantar fasciotomies, respectively. [14] In order to better guide treatment decisions with regard to surgery, Sammarco and Mangone have developed preoperative and intraoperative staging criteria based on a retrospective study of 18 patients and the corresponding lesion propagation and soft-tissue infiltration seen during subtotal plantar fasciotomy. While their study involved a small cohort of patients, Sammarco and Mangone’s criteria have shown promise at predicting delayed wound healing and may be of use when advising patients in the postoperative period. [15]

For the other forms of plantar fibromatosis, surgery is the only therapeutic alternative. However, in infantile forms, physicians should evaluate the need for surgery before performing it. [16]

Many juvenile fibromatoses spontaneously regress, and biopsy may be performed to induce their involution. Some lesions can grow, and others can recur after excision that appears complete. Because tumor growth characteristics may be relatively important before surgery, physicians should consider the possibility of an expectant control.

Hamartomatous plantar fibromatosis does not regress spontaneously; therefore, surgical removal is appropriate.

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Activity

Modification of activity, the use of orthotics, and physical therapy have been used as therapeutic modalities for the treatment of plantar fibromatosis.

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Complications

Ledderhose disease treatment complications, whether medical or surgical, often involve recurrence or incomplete treatment of the primary lesion. Following surgery, complications can include painful scars, wound dehiscence, nerve entrapment, and loss of arch height. Recurrence of the primary lesion is arguably the most damaging of surgical complications, often necessitating wider and more radical excisions, which presumably raise the risk of those complications previously mentioned. [7]

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